Consent for Purposes of Treatment, Payment and Healthcare Operations

I consent to the use or disclosure of my protected health information by Clifton Family Medicine, LLC for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Clifton Family Medicine, LLC. I understand that diagnosis or treatment of me, James Hild DO, Antonio Osio, MD, Andrea Babb PA-C, Tabita Balderas APRN, Carrie Parmely APRN, may be conditioned upon my consent as evidenced by my signature on this document.

I understand I have the right to request a restriction as to how my protected health information in used or disclosed to carry out treatment, payment or healthcare operations of the practice.

Clifton Family Medicine,LLC is not required to agree to the restrictions that 1 may request. However, if Clifton Family Medicine, LLC agrees to a restriction that I request, the restriction is binding on Clifton Family Medicine, LLC. I have the right to revoke this consent, in writing, at any time, except to the extent that Clifton Family Medicine, LLC has taken action in reliance on this consent.

My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review Clifton Family Medicine, LLC’s Notice of Privacy Practices prior to signing this document. Clifton Family Medicine, LLC’s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures drily protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the practice of Clifton Family Medicine, LLC. The notice of Privacy Practices for Clifton Family Medicine, LLC is also provided in the lobby and in each exam room.

This notice of Privacy Practices also describes my rights the practice of Clifton Family Medicine, LLC duties with respect to my protected health information.

The practice of Clifton Family Medicine, LLC reserves the right to change the privacy practices that are Described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling Clifton Family Medicine or visiting the website: and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.

I also, grant Clifton Family Medicine, LLC permission to view my medical record and prescription history from external sources.

If I am treated with scheduled prescription medicaions, I may be asked to sign a Pain Management Agreement. I will agree to only receive scheduled medications from Clifton Family Medicine.

I will keep my scheduled appointment. If an appointment is not cancelled within 24 hours, I may be charged $25.00 for the missed appointment.

CONTACT RELEASE INFORMATION: I agree to permit Clifton Family Medicine and their business associates to contact me, and all other resposible parties on my account, on our cell phone or other mobile devices concerning any and all aspects of my account.

I accept these terms and conditions

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